Contents

CanCer researCh Fundingdiabetes and the eye teaChing Cultural CompetenCe

news & opinion Letters2 Mandatory Rorting?

Dr Michael Marsh

Racism a Two-way Street Dr Julie Copeman

Indigenous Superclinics? Dr Olga Ward

Getting Behind Suicide Prevention Ms Amanda Wheeler

A Stitch in Time Dr Trevor Parry

Boyatzis-Capolingua Partnership A/Prof Amanda Bowen

Caesareans are Great! Name Withheld on Request

4 Spotlight: Prof Lyn Beazley8 Have You Heard10 Keeping Everyone Honest

MF

13 Pitching For Rural Doctors Mr Jake Millar

15 Giving Practices a Fresh Look17 Awakening GP Practice Market Beneath the Drapes19 Surgery, At What Cost?

Dr Rob McEvoy

21 Coming? Primary Care Reform in WA Dr Rob McEvoy

A GP With a Price Signal24 Babies on Bikes Public Hospital Performance Pharmacy Blooper26 Healthy Journalism in WA

Mr Jake Millar

31 Conference Corner

guest Columns23 Understanding Indigenous

Health Prof Pat Dudgeon and A/Prof Roz Walker

33 Early Intervention in Mental Health of the Young Dr Caroline Goossens

Clinical Focus5 Severe Mitral Regurgitation

Drs Eric Yamen & Chris Finn

7 Laboratory Diagnosis of Coeliac Disease Dr Mina John

31 Using Glycaemic Index with Weight Loss and Diabetes Ms Jo Beer

32 Awake Fibreoptic Intubation Dr Anthea William

34 Diabetes: Ophthalmic Manifestations Dr Bradley Johnson

35 In Tandem: Public Health and Medical Practice Dr Revle Bangor-Jones

36 Managing Rare Diseases in General Practice Dr Chris Fox

37 Rare diseases – Awakening Australia A/Prof Hugh Dawkins

43 Clinical Services Directory

lifestyle & entertainment27 Humour38 Competitions Humour39 Wine Review: Zema Estate

Dr Craig Dummond

40 Doctors Doing (Very) Different Things

42 Competition Winners – April Ancient Anecdotes

Dr John Quintner

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addition to established preventive measures it is clear that when there are concerns about developmental progress, early identification and intervention provides the best opportunity for a favourable outcome.Developmental surveillance in these early years is important and has been available in WA with an excellent service for many decades. However, with population increases not matched by staff increments in community and Child Health nursing, rationalisation has overridden professional priorities and some appropriate ‘health checks’ have been eliminated from the former schedule. In particular, the 18 month developmental screen has been omitted in favour of attention to earlier ages. This is a time when language development, symbolic play and increased problem solving are important to confirm – and if not emerging, an important time for further assessment and early intervention. Another concern is wait lists for appropriate further assessment and therapy, both in the public and private systems, and despite some recent improvements in services to Child Development Centres following some extra funding. However, there has been no significant increase in Child Health nursing – and insufficient ‘marketing’ to encourage young parents to attend for continued developmental surveillance for every child – when what is appropriate cannot be provided.It is known that $1 spent in the early years saves at least $17 spent in remediation subsequently. For the wellbeing of children now and for better outcomes for future society we need governments to adjust their priorities.

Dr Trevor Parry, Paediatrician

Racism a two-way street

Dear EditorYes, Prof Stanley, racism is indeed a key issue (Research Explores Aboriginal Health Failures, March edition) – being called a ‘f*** white c*** ‘ is not acceptable especially when someone in

Derbarl Yerrigan administration attempts to lightly dismiss it as part of my induction to Aboriginal health.Abuse of staff is rife within Indigenous health services. Having done a poster presentation at the RACGP Conference of 2008 I was stunned by the number of colleagues and ancillary health workers who wished to discuss how deeply traumatised they were by the experience of working in Aboriginal health. These staff were from all over Australia and stated they would never again work in Indigenous health.

Because of infighting within the Indigenous community and the tendency to lash out indiscriminately when a request is not acted upon in the manner the client desires, hundreds of thousands of dollars are being spent on security at our three metropolitan branches of Derbarl Yerrigan Health Service (DYHS) to try and stop staff being abused and attacked and to separate feuding clients.I have been informed that not a single local medical graduate now works in DYHS and they are paying huge sums for locums.If you lack accountability you are doomed to failure – for this reason the ‘merry go round’ continues with eight new CEOs at DYHS over the past few years and an ongoing inability to recruit and maintain staff.Hopefully, the answers as to why the major Metropolitan Indigenous Health Service is such a dysfunctional workplace will be within Prof Stanley’s research outcome report.

Dr Julie Copeman, MalagaEd. Dr Copeman demonstrates how racism impacts on people, whoever the protagonist. We understand she has a long-standing dispute with Derbarl Yerrigan - their spokesperson declined to respond. See p22 for a perspective on cultural competency training.

Indigenous Superclinics?

Dear EditorI am fascinated by the intermittent political hype about so-called Superclinics. As far as I can see, these appear to be clinics containing a team of GPs and allied health workers, all under

one roof, bulk billing patients for their services. Kind of like a shopping centre. Somehow this is supposed to transmute itself into magical great health for all the patients of such a service.I don’t know why the political movers and shakers think this is such a new idea. The Derbarl Yerrigan Health Service [formerly the Perth Aboriginal Medical Service] has provided exactly this type of one stop health shop since 1973, expanding and modernising its services along the way. Patients can obtain everything from dental care (the first five to arrive in the morning and prepared to wait) to medications dispensed on site, audiology, podiatry and a fantastic little treatment room and acute care facility. Not to mention a recall system that involves support from a team of dedicated Aboriginal Health Workers – all much needed, overstretched like the rest of us, and in constant demand. However, if facilities like this produce the results, surely our Indigenous population should be the healthiest in Australia?

letters to the editoreditor@mforum.com.au@

Mandatory rorting?Dear EditorIn reply to Dr Sara Bird’s article (The Mental Health of Doctors, May edition), her comments appear reasonable at face value in a perfect world, but there are practical undercurrents not addressed in her article.

She is assuming all employees in health services are honest and upright citizens, but research has shown that 1% of individuals in the workplace are sociopaths. Cognitive or unconscious bias is also a disruptive feature in the workplace and most of us, if we care to reflect on our careers, know of at least one individual we would wish to avoid.Framing of Mandatory Reporting legislation does not address the ever present potential for mischievous and vexatious complaints, and it is naive to leave such flaws in the legislation open ended, to the complainants discretion. Complainant fidelity in accusations and allegations made against medical practitioners is a joke, and must never be assumed.There must be stricter procedures incorporated in the regulations to prevent manipulation of the system, because of some initial perceived fault by a medical practitioner, and a backup mechanism that ensures steps in due process are strictly followed in a subsequent investigation. Qualified privilege should be suspended if this does not occur. Deliberate attempts to unjustly accuse a medical practitioner must be treated harshly to discourage this practice.The phrases “in good faith” and “to the best of my knowledge” place the accused medical practitioner in a precarious position, as it will lead to preliminary suspension and possible termination of their employment.I would like to see “the following factual evidence” and “the patient’s clinical outcomes” inserted into the legislation in its place. Anything less than this has the potential to lead to injustice.We all know that the written law can be an ass on occasions.

Dr Michael Marsh, Floreat

A stitch in timeDear EditorThere is now unquestionable evidence that the first three years of life are vital for healthy brain development for learning, health and behaviour (Kids Miss

Crucial Health Checks, May edition). In

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Promoting Science for the FutureFor prof lyn beazley, science has been a lifelong passion and she is now WA’s advocate for this field.

From her early studies in zoology at Oxford University to a career in biomedical research, and her current role as WA’s Chief Scientist, Lyn’s life in science has not been without challenges – whether solving WA’s skills shortage, tackling gender inequality or juggling work and family life. Looking back, she said science was not the natural path for her to take.

“I certainly wasn’t from a science-directed family. I was the first person in my family to attend university, though I’d always loved science at school. I initially went to university to read botany before swapping to zoology, and after that I had a career in medical research.”The catalyst for her science career was an evening lecture at Oxford by Prof Mike Gaze, who ended up as her doctoral supervisor.“He spoke about the ability of some animals to regrow their nerves and regain function in a way that doesn’t happen in mammals. This was intriguing and it started my career in the area now known as neuroscience – it actually didn’t even have a formal name when I started.”So she moved from zoology to neuroscience and to Edinburgh University to complete her doctorate and meet her husband, Clin/Prof Richard Tarala, current Director of Postgraduate Medical Education at Royal Perth Hospital.One daughter later – in fact it was 1976 and she was approaching school age – they looked past the horizon to Perth.“We were both offered posts at UWA and we initially decided to come for two years to see how it worked out. We thought it was splendid, professionally and for our family, so we have stayed.”With a successful career and now three daughters – all of whom are involved in science to some degree – balancing work and family life has been quite an act.“It’s always a challenge but it also helps you set priorities and ensures you have time management well organised. For me, having a wonderfully supportive partner also made a huge difference; we’ve always been a very close family and I’ve always seen family life as paramount.”Lyn’s work as WA’s chief science advocate is full-time. She remains enthusiastic about

spotlight

quality research and said the shift towards translational research has been positive, but basic research should not be forgotten.“It’s very important to see a balance because there are often opportunities for the best basic research to be translated for the benefit of the state. In WA we have so much to be proud of and certainly if we want the best clinicians it means we need the best medical research because the two are always very closely linked.”She promotes technology, engineering and maths as well as mainstream science.

Then there is the advice to governments on important issues.“It’s very important that each state embraces the concept of a Chief Scientist because it gives an independent voice to governments. I passionately believe that with the challenges our planet faces, science will play a very important part in ensuring a good future.”WA’s future is focussed on the resources boom, which cries out for good scientists. A greater uptake by women is part of the solution, particularly in fields like engineering where they make up as little as 20% of enrolments. Biology and medicine are better, but science

still remains a male-dominated domain. Lyn has never found this daunting.“It hasn’t been a disadvantage in the slightest and I’ve been extremely fortunate. UWA has a very strong program in supporting women in leadership roles but nevertheless there is still work to be done.”Just as her Oxford lecturer inspired her to pursue science, Lyn said teachers can be great motivators of children.“You start by having excellent science teachers. You really should be setting alight that love of science throughout primary school, and especially in the upper years because it will then flow through to high school.”Training scientists in WA is one thing; keeping them is another. What of the ‘brain drain’ that sees WA’s best talent moving interstate or overseas?“We need to have the best people and infrastructure we can offer to ensure when people come they can really perform optimally.”In this regard, she is keen on the Premier’s Research Fellowship Program that offers a $250,000 annual package for four years. Nine fellows have been appointed so far and each has become a science ambassador, much like Lyn. Her enjoyment in that role is obvious.

“It’s a tremendous chance to see what’s happening in WA from Kununurra right down to Esperance and Albany, and I was in Merredin recently to see the biggest wind farm in Australia being built there. I really appreciate the opportunity to see the potential of science across our great state.”“I’ve had a very busy life, but I would much prefer it that way.” l

I passionately believe that with the challenges our

planet faces, science will play a very important part in ensuring a good future.

medicalforum 5

Mitral regurgitation (MR) is the second most common clinically significant valvular disease requiring intervention. Each year in Australia, more than 4000 mitral valve replacements

or repairs are performed for MR, which is a complex clinical entity. MR has several potential aetiologies, the most common being valvular degeneration (prolapse) and functional regurgitation from left ventricular (LV) dilatation or impairment.

Severe untreated MR can lead to progressive LV dilatation, LV systolic impairment and heart failure, arrhythmias, pulmonary hypertension with right heart compromise and ultimately death. Open heart surgery is offered to patients with severe MR and symptoms, or asymptomatic patients with evidence of incipient or established LV compromise (dilatation or impairment). However, certain subgroups of patients (e.g. the elderly, those with prior heart surgery, significant LV compromise or other comorbidities) face greater risk from open heart surgery and thus may not be offered intervention; they are in need of a less invasive option for repair of MR.

the mitraCliptm systemThis is the first commercially available percutaneous device designed to treat mitral regurgitation. The clip is a polyester-covered mechanical device with two mobile arms and grippers used for capture of the valve leaflets (Figure 1). The device is passed into the left atrium via the femoral vein and across the interatrial septum. The arms of the clip then attach to and appose the central portions of the anterior and posterior leaflets, reducing regurgitation and forming a double-orifice mitral valve (Figure 2). More than one clip can be placed to achieve the desired reduction in MR. The procedure is performed with trans-oesophageal echocardiographic (TOE) guidance under GA, and takes 3-5 hours. Cardiopulmonary bypass is not required and the clip is placed on a beating heart, with the advantage of real-time assessment of reduction in MR. Greatly reduced postoperative recovery times are important in the elderly or sicker patients, with discharge at day 1 or 2 post-op.In the first months after implantation, the clip is endothelialised, and a tissue bridge forms across the mitral valve. Warfarin is not required, but can be used if the patient has a separate indication for anticoagulation. Aspirin and clopidogrel are used for the first three months.

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Worldwide experience and dataAlmost 5000 MitraClip implantations have been performed since the first in 2004, predominantly in Europe. The landmark Everest II study1 was a randomised control trial comparing the MitraClip to traditional mitral valve repair or replacement and recruited 279 patients, mean age 65, with severe MR and an indication for valvular intervention (86% had a history of heart failure). Implantation success was 77% and while the degree of MR reduction in MitraClip patients was slightly worse than with surgery, among patients with a successfully implanted clip, outcomes were similar to the surgical cohort (i.e. persistent reductions in MR to two years, improved functional class and quality of life). Additionally, MitraClip proved safer than surgery, with lower rates of transfusion and stroke.The European experience has concentrated on high risk patients with functional MR, LV impairment and severe heart failure. In registries from high volume centres, procedural success is excellent (>95%) with very low complication rates and significant reductions in symptoms and heart failure hospitalisations.

the Wa mitraCliptm programA multidisciplinary team has begun implanting the MitraClip, the first at Sir Charles Gairdner Hospital (and in Australasia) was in March 2011.

Patient selection: the procedure is not being offered to young healthy patients who are likely to have a good outcome from traditional open heart surgery. Instead, older and sicker patients, perhaps not previously considered for any cardiac intervention, are undergoing screening that includes TOE to determine if the valve is anatomically suitable for the device, and in most cases cardiac catheterisation. More details of selection criteria are available on request from eric.yamen@gmail.com.

14 Cardiologists, together with Ancillary Staff, provide a comprehensive range of private Adult and Paediatric Services.

Visit www.westerncardiology.com.au to search information on locations, cardiologists and services.

Severe mitral regurgitation: the MitraClipTM device

by drs eric yamen & Chris Finn, Western Cardiology

n Figure 2B. Post-operative 3D Transoesophageal Echo: The MitraClip has been positioned centrally resulting in a double orifice mitral valve and improved mitral regurgitation.n Figure 1: MitraClipTM device

n Figure 2A. Pre-operative 3D Transoesophageal Echo: This 3D view of the mitral valve, taken prior to device placement, is from the left atrial perspective which allows guidance of the clip into the correct position.

summaryThe MitraClip is the first commercially available device for the treatment of mitral regurgitation. Implantation of the clip is safer and less invasive than traditional mitral surgery, and in properly selected patients, can lead to marked improvement in symptoms and quality of life. The program at Sir Charles Gairdner Hospital, led by Western Cardiology doctors, is currently screening patients for the procedure. References:1. Feldman T, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med. 2011 Apr 14;364(15):1395-406.

Others available on request. n

medicalforum 7

Laboratory Diagnosis of Coeliac Disease

By Dr Mina John, Clinical immunologist &

immunopathologist

It is also increasingly recognised that clinical coeliac disease can develop in adulthood. While children are more likely to present with florid malabsorption syndromes, adults may present more incipiently with isolated iron deficiency anaemia, other vitamin deficiencies, persistent transaminitis, osteoporosis, infertility, recurrent miscarriage or uncommonly, with dermatitis herpetiformis and certain neurodegenerative symptoms. Indeed gastrointestinal symptoms may not be prominent nor associated with low body weight. Some individuals are asymptomatic but have other high risk factors such as a concurrent autoimmune disease, including type 1 diabetes and autoimmune thyroid disease. The contemporary view of coeliac disease is that of a clinically heterogeneous and frequently unrecognised disorder. Pathology services play a key diagnostic role. Effective use of serology and genetic tests is important in reducing unnecessary intestinal biopsies in those without coeliac disease and returning more confirmatory biopsies in those that do.

diagnostic tests reflect pathogenesis of diseaseLike many autoimmune conditions, coeliac disease results from the confluence of genetic predisposition (most importantly in HLA-DQ genes but up to 39 other non-HLA genes) and external triggers (gluten in wheat, rye and barley, possibly enteroviral infections) (2). HLA genes encode molecules that bind and present peptides derived from pathogens, drugs or environmental proteins to the immune system. The reason why only particular HLA types (HLA–DQA*0501, -DQB*0201, -DQA*0301 and –DQB*0302) are involved is because they are uniquely shaped to bind gluten-derived gliadin peptides.

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There must be other, as yet undefined, reasons why only about 4% of those with these relatively common HLA types (i.e. ~25% of Caucasians) go on to develop an inflammatory response in the small bowel. An initial inflammatory response releases an intracellular enzyme called tissue transglutaminase (tTG). There is tTG-mediated modification (deamidation) of gliadin proteins that renders them more stimulatory to the immune system and this in turn promotes a self-amplifying cycle of reactions against deamidated gliadin and the auto-antigen tTG, release of pro-inflammatory cytokines, and further tissue damage. A gluten-free diet reverses the pathology by removing the antigenic stimulus of this inflammatory cycle. In the small proportion of patients with diet-resistant coeliac disease, the inflammatory process broadens to involve aberrant cells and more innate immune system responses that operate non-specifically and therefore autonomously. Given this pathogenetic model, blood testing for antibodies to tTG or antibodies to gliadin/deamidated gliadin peptides, provide the evidence of a gliadin-specific immunological reaction, and this predicts the final tissue pathology (lamina propria inflammation, intraepithelial lymphocytes, crypt hyperplasia, villous atrophy), which mediate symptoms and should be sought on intestinal biopsy. This also explains why HLA genotyping can only show that an individual has the genetic background that is necessary, but not sufficient, for development of disease.

diagnostic testingThe current anti-tTG IgA assay or the anti-deamidated gliadin peptide (DGP) IgA/IgG assays are highly sensitive (80-90%)

and specific (90-99%) screening assays for coeliac disease, and have superseded previously used assays. A positive result has a high positive predictive value for presence of disease however absence of this antibody does not necessarily exclude disease if there are suggestive symptoms. Because of common genetic susceptibilities underlying both coeliac disease and selective IgA deficiency, anti-tTG IgA should be interpreted with reference to total serum IgA. If there is absolute IgA deficiency, testing for the alternative DGP IgG should be undertaken. Antibodies (along with the pathological changes on intestinal biopsies) decline during gluten withdrawal and it is therefore important that the person follows a gluten-containing diet for 6-12 weeks before test. HLA-DQ genotyping is not affected by gluten exposure and is useful in circumstances when the diagnosis needs active exclusion. First degree relatives have a 10-20% increased risk, so genetic screening can either exclude susceptibility or identify those for further clinical and antibody screening. Demonstration of characteristic and reversible small bowel histopathological changes is required for a diagnosis of coeliac disease. This provides the best evidence for life-long dietary restriction. The challenge for clinicians remains to deliver the four out of five individuals with undiagnosed coeliac disease to confirmatory small bowel biopsy by awareness of less obvious clinical presentations and using available testing effectively. References 1. Anderson P et al. Coeliac disease is on the rise (Editorial). Med J Aust 2011, 194 (6);278.2. Trynka G, Wijmenga C and van Heel D. A genetic perspective on Coeliac disease. Trends in Molecular Medicine 2010,16(11);537-549

Though the diagnosis rate of coeliac disease in Australia has increased over the last ten years, an estimated four in every five individuals with the disease remain undiagnosed, based on a

population prevalence of 1%(1). The increased diagnoses worldwide may reflect a true rise in disease prevalence, not just improved detection, as exposure to gluten-containing food such as bread and pasta becomes globalised to populations whose historical dietary staples of rice, maize or millet are gluten-free.

8 medicalforum

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Charity checks in storeWhen we surveyed WA specialists (October 2010) 55% said there were too many not-for-profit health organisations in WA. Now a new Australian Charities and Not-for-profits Commission will be introduced to crackdown on charities following this year’s Federal budget. National regulation is in the pipeline. The legal status of all groups wanting to be classed as charitable institutions will be reviewed. Minister says NFP tax concessions should only be used to assist disadvantaged people and not for unrelated commercial activities. FBT and GST concessions for commercial activities will be reviewed.

boys’ hpV jab ruled outA CSL bid to have their HPV vaccination program extended to adolescent boys has failed due to uncertain cost-effectiveness. The PBAC was not convinced by some of the modelling from CSL that included evidence for the vaccine’s ability to protect against genital warts and pre-cancerous lesions, as well as penile and other cancers.

hedland makes it officialIt opened doors in November, but Health Minister Kim Hames only recently officially launched the new $138m Hedland Health Campus, the newest regional hospital in Australia (Albany, Kalgoorlie and Busselton to follow). Commemorative plaques were awarded to, amongst others, Dr Malcolm McCallum, Dr Allan Vickers, Dr Philip House, and Dr Pascall Burton. Hedland Health brings the Pilbara 24/7 ED, obstetrics and paediatrics wards, day surgery, renal dialysis, medical imaging and outreach specialist services.

no stop to retirement qualmsThe ruckus around the working future of semi-retired doctors will not quieten. Many are involved in charitable overseas work for which registration in the country of origin is a requirement. Others take up teaching posts with UWA or Notre Dame, become an examiner for the MAC or even sit on the Medical Board. You would expect all of them to be registered to assume these positions but

current national Medical Board requirements for ongoing CME and fees will drive many away once three-year period of grace on “Occasional practice – special purpose” comes up. It has been suggested that a third of the university-based medical educator workforce could be lost under the new rules. Remember Dr Bruce Shepherd and the Australian Doctors’ Fund (ADF). It is now lobbying to reinstate the rights of retired doctors (WA leads the way again) - a ‘senior active’ category with a $100 registration fee, a minimum CPD of 10 hours a year, self directed, and an annual medical certificate.

raCgp readies for e-healthHas anyone noticed how the latest accreditation criteria for the RACGP help position the college as a provider with the Federal Government, in the e-Health race? First, we now have a 70% (up from 50%) requirement that active patient records include a health summary (with standardised terminology or coding). The RACGP is promoting its health summary for the purpose. Second, patient identification should include three approved patient identifiers, presumably to improve data integrity and remove duplicate records. Third, a new criterion that practices maintain accurate medicines lists for patients.

nice work if you can get itDr Neale Fong’s corporate experience in the health sector makes him an invaluable asset in mineral explorations. Chrysalis Resources Ltd (ASX:CYS) has Neale as its non-independent Executive Chairman. The company’s last quarter report has it spending more on administration ($200k) than exploration and evaluation ($150k). It is burning about $100k per month of cash reserves, having listed on the ASX in May 2008 and built $2.15m investor cash reserves by June 2010. The last annual report says Dr Fong receives $100k per year (plus 1.0m share options, value $158k), to which he can add $74k p.a. from his non-executive position on the Realms Resources (ASX: RRP) board, another mining company which also gave Dr Fong a $150K interest-free loan.

Euthanasia support alive and wellSince the NT’s Marshall Perron introduced the Rights of the Terminally Ill Bill to Parliament in 1995 (and the feds overturned it in 1997) the campaign for the right of people to choose their end has died down (excuse the pun).

YourLastRight.com is now on the campaign trail and a lot of high profile Australians are in their camp. You can see them on the website, along with the PollieScanner, which says in WA, six politicians support the concept, 21 are opposed and 91 have an unknown position. The latest is the national alliance of all State and Territory Dying With Dignity and Voluntary Euthanasia societies to campaign for legislation to allow rational, adult Australians experiencing intolerable and unrelievable suffering from a terminal or incurable illness, access to aid-in-dying from a doctor, after appropriate checks and reviews. They have released research findings from Oregon, where physician-assisted dying was legalised in 1997, saying the death experience as good as or better than non-assisted deaths.

Wa research going strongOverweight men with were less likely to develop dementia than those of normal weight according to a 10-year study of 12,047 men aged 65 and 84 years. The results from UWA-based WA Centre for Health and Ageing seem to support a review of BMI guidelines for the elderly. Another local study, this time from WAIMR, found desk jobs can double people’s bowel cancer risk. Those who work for a decade or more behind a desk have a 44% increased risk of rectal cancer. The two-year study by UWA PhD student Terry Boyle involved men and women aged 40-79 and included 918 cases and 1021 controls. It was published in the prestigious American Journal of Epidemiology. In more good news for WA research, last month construction started on the $100m research hub at the QE II Medical Centre. It will house around 800 researchers when it opens in 2013.

editor@mforum.com.au or ring the editor on 9203 5222

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10 medicalforum

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Keeping Everyone Honest

ethics in medicinemF

Australians are very lucky to have a judicial system and various codes that protect consumers from unscrupulous commercial conduct. What is more, the overseeing authorities are given some teeth, which results in a meaningful watching brief while attempts at self-regulation play out. In health, there is growing awareness around unethical practice and conflicts of interest, helped along by some legislated transparency. The relationships between doctors and the pharmaceutical industry have been closely scrutinised (and medical equipment providers and researchers are probably next in line). Some argue that transparency is not enough and articles such as this should be written by people with no conflicts of interest!

One good example of system reform is the ACCC’s granting of three-year conditional authorisation to the Generic Medicines Industry Association’s (GMiA) Code of Practice. This code is a self-regulatory framework for the supply of generic medicines in Australia.The ACCC has responded to concerns by placing conditions that provided greater transparency around the relationship between manufacturers of generic medicines and pharmacists. Manufacturers are now required to publicly report on the hospitality and entertainment provided at educational events to both medical practitioners and pharmacists. Secondly, gifts and other non-price incentives

provided by manufacturers to pharmacists as an incentive for them to stock their brand of product must be reported annually. There was concern that the offer of loyalty programs or other non-price incentives to pharmacists undermined public confidence in the generic medicines industry, which can apply to S2, S3 and S4 prescribing. Most concern centred around brand substitution and some dubious ‘educational’ entertainment dished out to doctors and pharmacists in the past. Even Medicines Australia thought the GMiA code was too weak.A short time before this decision by the ACCC, the Australian Centre for Independent Journalism posted an interesting story around a biased report on a new drug treatment for leukaemia that appeared in a major Victorian newspaper.It turns out that the press release that the report was based on came from a reputable clinic, but via a clinician who was not only on an advisory board for a pharmaceutical company but was passing on PR material that originated from that company, albeit via the company’s PR media outlet. The same media outlet had featured in Media Watch for promoting prescription medication to the public on behalf of its pharmaceutical clients. There is growing awareness that PR companies employed by pharmaceutical companies are being engaged to deliver drug endorsements to

the media, which has a tendency to uncritically report these endorsements. The fact that this happens to create illness or treatment awareness (without promoting a product), perhaps when the drug is being presented for PBS listing, is a striking coincidence. Indirect promotions (such as websites) are also problematic. Last year, Roche was fined $200,000 for offering a regional public health organisation funding for a nursing position in exchange for doctors in the region prescribing its hepatitis drug. A health professional

complained to Medicines Australia. Normally, rival pharmaceutical companies complain. The code says no inducements should be offered that could

interfere with a health care professional’s independence.Roche was also fined $200,000 for making misleading claims about its renal anaemia treatment and was ordered to stop using all relevant promotional materials. Withdrawal of advertising, fines and published retractions are imposed under the voluntary code but the fines would be relatively small in comparison to the companies’ advertising budgets or potential earnings from a PBS listing. This is all about pharma-related promotions in Australia. But there is another angle. Many doctors are probably unaware that colleagues who travel to overseas conferences or meetings may be sponsored, or that clinical trials or training may be underwritten by industry. The recent announcement by GlaxoSmithKline (GSK) may have somewhat lifted the lid on this. The company has decided to go beyond the required reporting of sponsored Australian educational events to now disclose:• Allconsultancyarrangements(suchas

advisory board honoraria, speaker honoraria, speaker training, other types of consultancy) as well as travel to all of these,

• Sponsorshipofregistrationtoattendcongresses (international and local), travel to international meetings and overseas costs such as meals.

• Grantsanddonations(non-monetary)toindividuals and institutions.

Is there is an element of “coming clean” in GSK’s decision? What has been happening?The flipside is that such blurring of boundaries would not happen if all doctors were unwilling to compromise their professional independence. We all assume doctors act, primarily in the patients’ best intersts. l

Cleaning up the relationships between doctors and commercial medical interests is an ongoing struggle that requires diligence and determination.

Even Medicines Australia thought the GMiA code

was too weak.

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medicalforum 13

Insurances fall within the category of a must have expense that one hopes they will never need.

But as medical professionals know from experience, the requirement for insurance cover – whether it be health, life or trauma insurance – is far greater than most people realise.

Financial adviser Murray McKinley says one of the least subscribed insurances among the general Australian population is trauma cover – an insurance which provides a tax free lump sum payout for major illness or injury.

Mr McKinley, a director of McKinley Plowman accounting and financial planning firm, says while many medical professionals have trauma insurance for themselves and their partner, a lot don’t have it for their children.

He says trauma cover, which provides a payout for up to $200,000, is available for children aged between two and 18 years and can be attached to a parent or grandparent’s trauma policy.

This relatively new insurance cover, which costs around $1 a month for each $10,000 worth of cover, is less expensive than most people’s car insurance.

Mr McKinley says the risk protection of child trauma cover provides the peace of mind that one will have the money to do whatever is needed to treat their child.

“These events are difficult enough to deal with without adding the financial stress that may come from being away from work or out of the practice,” Mr McKinley says.

Mr McKinley says Australians generally tend to be fairly careless about ensuring adequate life and trauma insurance cover for themselves and their families.

“In my younger days I was quite sceptical about insurances and probably saw myself as invincible,” Mr McKinley says.

“However, my professional life has changed any reservations that I’ve had about insurances because I’ve seen a lot of clients claim on these policies.

“Had these people not had insurance cover, their lives would have been even more stressful.”

Mr McKinley says before signing up for any sort of insurance cover it’s important to consult with a trusted financial or insurance adviser to find out which policy is most suitable for one’s circumstances.

Important insurance advice

For more information phone Mr McKinley on 9301 2200 or visit www.mckinleyplowman.com.au

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Pitching For Rural Doctors

doctor recruitmentMr Jake Millar

With such high demand for rural GPs throughout WA, large salaries and generous relocation packages are par for the course. The financial rewards being offered to lure GPs away from the city range from lucrative to astounding, but there are some regions looking to move away from the one-upmanship by promoting other unique benefits.

Doctors looking to move to rural WA can expect to receive salaries anywhere from just under $200,000 through to $500,000 a year. They are also likely to have moving costs, a furnished home and a car thrown in.Southern Regional Medical Group CEO Mr Chris Swarts has been involved with doctor recruitment and says the situation is bleeding many areas dry.

“Obviously it is not sustainable and that’s why we’ve been looking for an alternative solution. We’d like a fly-in, fly-out service where doctors travel to these rural communities from a base that caters for their needs in terms of family support and lifestyle,” he said.“In the interim, while we try to get the necessary funding we’ve been managing their practice with locums and that’s costing us $1800 a day, plus recruitment fees, which is 16% on top of that. Those

locums get flights, accommodation and a car, so the whole situation is a bit ridiculous.”In addition to paying top dollar for GPs, Pilbara Health Network CEO Mr Chris Pickett said housing prices in some areas are making a difficult situation worse.

“It’s a critical issue because you’re paying upwards of $1600-1700 a week for a house up here. Unless you can bring a doctor in with housing, you’ve got another $75,000-100,000 a year in house rental to find.”Although it is tough, Chris said they do try to promote the advantages of their region.“Our attraction’s the ocean and the fishing so we make sure the doctors can get some good exposure to the coastline up here because it’s pretty sensational.”

“We’ve also got a very strong focus on Aboriginal health and we get a lot of young doctors who like to get a grounding in Aboriginal health, so we try to attract them on that basis too.”Wheatbelt GP Network CEO Mr Paul West has been working with shires on doctor recruitment and agrees that rural areas should offer GPs more than just money.

“In Wyalkatchem they have an aviation flight academy, so they offer new doctors a scholarship to learn how to fly. It’s only $5,000 or so – chickenfeed compared to what a doctor’s earning but it’s a unique hook that gets interest.”“At Yilgarn they negotiated with one of the mines to provide a seat on their aeroplane each way once a week. So they can live with their family in Perth and it’s just a 45 minute flight after breakfast on a Monday morning,

and they’re home for dinner on Friday night.”Dr Brenda Murrison, Medical Co-ordinator at Brecken Healthcare in Bunbury said she has been working very hard on doctor recruitment.

“I have interviewed literally hundreds of doctors. It hasn’t happened quickly and it hasn’t been a miracle by any stretch of the imagination – we’ve recruited as a result of a long and protracted effort over a period of years.”Brenda said one area they have worked on is the style of practice.“We have a full multidisciplinary team on site,

How far is too far and will it work?

including psychologists, practice nurses, exercise physiologists, physios and a pathology collection centre.”“Of course, we’re also offering them a lifestyle choice because they don’t have to be on-call every night. It’s one four-hour shift a week.”Notre Dame Director of Primary Healthcare Research Prof Tom Brett has studied medical workforce issues and said getting a doctor with links to an area is a big plus.

“Those with a rural background are much more likely to work in rural areas. Also, if they have a spouse with a rural background, irrespective of whether the spouse is a doctor or not, it is also a huge plus to ending up working in the community.”Tom said part of the solution is to actively seek medical students from rural areas, with a rural commitment in the selection process, along with both undergraduate and post-graduate training placements in rural practices.

“The last couple of years the good thing is that the community applications to rural stream training for GP registrars has been oversubscribed.” Other factors were the sort of work-life balance sought, the feminisation of the workforce, schooling facilities (especially high school) and community facilities. l

n Mr Chris Swarts

n Prof Tom Brett

n Mr Chris Pickett

n Dr Brenda Murrison

n Mr Paul West

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Awakening GP Practice Market

medical real estateMr Jake Millar

Things slowed up a lot after the heady days of corporate bidding for general practices, when goodwill payments largely evaporated. However, as some doctors came off contracts from within bigger practices, they had seen enough of modern lean practice management to apply it to establishing a smaller boutique practice, where they had more say in what went on. And the tide of overseas graduates is gradually drifting to urban areas and looking for a niche. Medical Forum spoke to Health Linc’s Brad Potter who has been more or less watching from the sidelines until more recent times.

Brad said the market for GP practices remains slow and interested buyers are not paying much for properties. In comparison, dentistry business sales have been booming. So why are more dentists buying than GPs? Brad explained it is comes down to the bottom line.“In general practice, people out there are paying employees 65-70 cents for every dollar of revenue they’re generating,” he said.“On the other hand, an employee dentist gets about 40% of the revenue they generate. So it makes sense that someone who’s an employee of a dental practice would rather own their own practice. Why would someone in medicine who is earning 70 cents in the dollar of their fees own their practice unless they had a burning desire to run a business?”

a good time to buy?However, Brad said this lull in the GP market means there are opportunities to find relatively cheap practices in good locations.“It’s probably a good time to get into the market because of the relatively low entry level price to buy a practice. They are selling for less than what you could set one up for from scratch, and they’re normally in reasonably good locations.“The corporates bought out all these practices and they have now shut the doors and amalgamated them into big super clinics. The people that have been working in those practices don’t want to go to these big super clinics because they want the smaller, family-orientated businesses.”“In the next three to five years we’ll find the value of a GP practice will increase.”Brad said this is partly because a lot of the interest for practices is coming from overseas doctors.“We had a shortage of doctors about ten years ago so we’ve got all these overseas-trained doctors who had to go to areas of unmet need in the country.”“Now they’ve done their service in the country and they want to move back to Perth and put their kids through school.”

things to considerBrad shared a few basic tips for those looking to enter the market.

We take a look at shifting trends in the WA GP practice market, through the eyes of one established player.

n Mr Brad Potter

“You’ve got to look at the motivations of why the guy’s selling and more often than not, they’ve just had a gut-full and want to retire. A lot of these people I’m dealing with are in their seventies and they’ve kept working because there’s been such a shortage of GPs.”He said it is also important to consider the technology in use, potentially a big ticket item, particularly paperless systems for patient records or scripts if this is a priority. It is also wise to look at the practice’s employment arrangements.“Look at what sort of contracts they have their doctors on because some people employ three or four doctors and some might not have them on any contracts. For a buyer to come, they’d want to have a restraint of trade which says they can’t open up within a certain radius. Certainly that can pull the bottom end of a practice out pretty quickly if people choose to open up themselves or move to another practice.” l

u Mr Chris Flynn has accepted the role of CEO at St John of God Hospital Geraldton. Chris has worked in the Catholic private health sector in regional Victoria and in Brisbane.u Dr Ronnie Hagan has been appointed new Medical Director at Mercy Hospital.u After 35 years as a Silver Chain volunteer, and almost 23 years as Silver Chain Albany Branch Committee President, Mrs June Hodgson will be retiring in July.u Three WA nurses and midwives each received a $20,000 fellowship from the Nursing and Midwifery Office to fund research projects to improve patient care. Ms Fenella Gill (Paediatric Intensive Care); Ms Ce Kealley, (Peri-operative Services, Kaleeya); Ms Sarah Nicholls ( Midwife, Kaleeya).

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medicalforum 19

Surgery, At What Cost?

medical market ForcesDr Rob McEvoy

May’s editorial looked at market forces applied to the private-public hospital debate and the activities of anaesthetists. Generalisation is always difficult, but in WA trends are emerging as the squeeze on health finances kicks in. As well, various financial changes have impacted on clinical practice, from no-gap health insurance products and benchmark pricing of prostheses to changes in accreditation standards and fly-in fly-out medicine.

In May last year, an orthopaedic surgeon (who wishes to remain anonymous) wrote to us with a dilemma that is worth exploring here.The surgical scene is changing. WA has pioneered surgical audits in public hospitals, surgeons are now subject to credentialing at all levels, and the RACS encourages its surgeons to ensure informed financial consent before embarking on any procedure. It says “the imparting of likely financial implications of the proposed treatment is sound ethical, professional and business practice. It indicates respect for individual patients and their rights, and avoids negative perceptions of private medical practice” (Informed Financial Consent Policy, October 2009). To give an idea of how perceptions are changing, 124 specialists gave these responses to our statements back in September 2004:

For elective surgery, the onus is on the surgeon to find out the anaesthetist’s fee and include this in the patient’s quote for surgery.Agree 29% Disagree 63% Uncertain 8%There is no excuse these days for not fully declaring to private patients the estimated out-of-pocket expenses they will face from all those involved in routine elective surgery. This includes pharmacy, physio, dressings etc.Agree 66% Disagree 30% Uncertain 4%

When we surveyed 13.6% of all GPs in August 2007, they were quite vocal about the impact specialist out-of-pocket fees were having on them and their patients.

While they thought only 11% of their patients put out-of-pocket expenses as the most important factor during referral, 79% of GPs said that patients complained about cost after their specialist encounter (consult or procedure), 7% very often, 26% often and 46% occasionally.If a patient complains about that specialist’s costs, just over half GPs said they would divert the referral, either by telling the patient to find a cheaper specialist (34%) or by finding one themselves (18%). A minority (17%) push on with the referral and tell the patient to take up costs with the same specialist.Only 13% of GPs thought it was their job to vet out-of-pocket specialist costs before referring a patient (16% uncertain) but 82% said patients should be better forewarned of specialist costs and a third said these specialties charged inappropriately high out-of pocket fees for private

patients (in order) – orthopods, dermatologists, anaesthetists, psychiatrists, obstetricians, and plastic surgeons.

Certainly, money concerns are currently at the forefront of patient complaints about surgeons, particularly unheralded ancillary costs. Now, the College of Surgeons (RACS) says the cost of the anaesthetist, surgical assistant, pathology, imaging and allied health should be part of gaining informed patient consent, in writing, and gap payments and Medicare refunds should be outlined. The reality is that some surgeons, for some procedures, are now competing on price.The whole scenario of informed financial consent comes into stark prominence as wait lists increase for both appointments and procedures in public hospitals, particularly where the person is young and is seeking an early return to work. If these patients do not have private health insurance but are earning zillions up north, a quick fix becomes top priority. Other situations apply, such as people in chronic pain.Our orthopaedic surgeon said he is seeing more uninsured patients wanting to self-fund private surgery. Some of his colleagues avoid such cases because the referring GP has often grossly underestimated costs to the patient, they say providing an accurate comprehensive quote for the procedure is problematic, and if complications arise the patient cannot handle the cost blowout. At other times, the patient wrongly believes that can get fast tracked onto the public list by seeing someone in private.The RACS says there is the potential for subtle coercion of patients into paying privately for some procedures. “Surgeons should give accurate advice about waiting times in public hospitals and accurate information about the

The pressures that bring more uninsured patients to ask for procedures privately should be responded to appropriately if the profession is to avoid criticism.

alternate forms of care and the subsequent costs. There should never be coercion (or the impression of coercion) for patients to be treated in the private health care system.”Our orthopod suggested that while most things could be worked through between surgeon and patient, Medical Forum would be doing a good job if it gave GPs a better idea of private hospital costs. We are not sure about that but here goes with some figures supplied by surgeons, some going back a year or two. We invite our readers to comment on these issues via medicalhub.com.au or editor@mforum.com.au. l

Orthopaedic: Day Case Arthroscopy

Surgeon $1380Surgical Assistant $276Anaesthetist $560Theatre $1332Day Bed $460Pharmacy $40Total: $4,048

Vascular: Abdominal Aneurysm

Graft cost $12-30,000Surgeon $3300Assistant $340Anaesthetist $1800CT scans $1000Additional: Theatre fee, drug costs, bed days (2-3 with 1 ICU) Total >$22,300

Orthopaedic: Hip replacement

Prosthesis $10,468Bed days (up to 10) $8540Surgeon $1822Assistant $333Anaesthetist $900Theatre $6026Physiotherapy $550 Imaging $82Total $28,721

General: Lapbanding

Prosthesis $3800

Bed days (2 days) $1700

Surgeon $3000

Assistant $600

Dietician $100

Additional: Anaesthetist, Theatre fee

Total >$11,100

20 medicalforum

Coming? Primary Care Reform in WA

primary health CareMF Review

WA Health Networks people, under the leadership of Dr Scott Blackwell, have come up with a plan to shape the future of primary care in WA. July 7 is the deadline for written feedback on the Primary Health Care Strategy – Consultation Document. There will also be urban meetings and workshops, and the WA Country Health Services will talk to their people but individual comments are welcome. You can get hold of a copy at 9222 0200 or www.healthnetworks.health.wa.gov.au/network/future.cfm and to spur you on, we present some details here.

First off, realise that primary health care providers include GPs, nurses, midwives, allied health providers, Aboriginal health workers and pharmacists. And the push primary health reform, no surprises, comes from:• Morechronicdiseases• Inequalities,particularlyforAboriginalpeople• Anageingpopulace• Obviouscurrentservicedeficienciesand

duplication• Alackofcommunityservicesinmentalhealth

and drug/alcohol areas.

Medical Forum looks at the HDWA’s discussion document along the road to primary health care reform in WA. Now is the time to provide feedback.

While national goals are echoed – integration and infrastructure, e-Health and IT, workforce, cost and performance – the WA priorities are mainly focused on Aboriginal health, aged care, mental and drug/alcohol health, and maternal/child health. The ideas come from the Primary Care Strategy Working Group, the Primary Care Health Network established in 2008, and about 200 other groups/individuals – leading to around 80 strategies to achieve results.What are they? You have only 30 pages to digest, the bureaucratic jargon may be a pain and repetitive, but the print type is big and it is well laid out. Try these thought-provokers first….• Aconsequenceoforreasonforbuilding

primary care capacity is to take pressure off the hospital system, and two pre-requisites will be “cultural change and mutual respect” and “embracing the development of e-Health”. p 8.

• ReformurgencyisunderpinnedbyWA’scommencement of Activity Based Funding and Management, with a key principle being an emphasis on community-based care to reduce hospital service demand. p 10

• TheestablishmentofGPSuperclinicsisanopportunity for the local community to have greater access to primary care and Medicare

Locals may provide a system to manage and deliver services in WA. p 15

• Reformsshouldbesupportedbyevidence– perhaps by partnerships with universities, research organisations etc – with research encouraged and supported. p 18

• Strategiesforregionalintegrationincludeservice delivery in areas of need or poor access, outreach specialist services, and reduced hospital-based care when communities can do it better. p 20.

• RevisethePrivacyActtoaccommodateastatewide mandatory e-Health platform – a single platform that integrates with everyone and is compatible with the national unique patient identifier initiative. p 22

• Exploregeneric-basedmentalhealthworkersand chronic condition co-ordinators within primary care. p 23

• EnhanceworkforceskillsthroughappropriateAboriginal cultural awareness training. p 26

• Introducegeriatricexpertisetothemanagement of patients presenting to EDs. p 29. l

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Where to with Cultural Competency?

indigenous healthtraining

The Federal Government’s recent decision to ensure companies bidding for large government contracts in regions with a significant Indigenous population employ Indigenous Australians and use Indigenous suppliers, is one form of affirmative action to “bridge the gap”. An accreditation course in “cultural competence” is another. However, such initiatives will attract controversy against a setting of many years of failed attempts to assist 2.4% of the population out of its social, economic, cultural and health difficulties. Are doctors and other health workers “culturally competent”? While no course is going bring about a generational shift, is it a step in the right direction? Does it mean everyone else is culturally incompetent?

I took a crack at the online Aboriginal and Torres Strait Islander Cultural Competence course from the Centre for Cultural Competence, Australia (www.ccca.com.au). It leads to TAFE NSW accreditation, there is a fee, and it has been endorsed by the NSW General Practice Network, the RACGP, the RCNA, ACRRM and The Australian Psychological Society.

Dr Rob McEvoy relates his excursion into achieving ‘cultural competency’ through online learning.

Once online, the course is simple, and you can come and go at your own pace, resuming where you left off. There are 12 components, each comprised of videos or reading followed by questions, with an estimated overall course time of about six hours.Going into this with my prejudices, there were some aspects I found contentious, but overall I learnt heaps about Aboriginal cultures and events, and the likely impacts on the doctor-patient encounter. Some of the language will fuel prejudices, such as “Aboriginal nations”, but this is insignificant in the broader context. After years of experience, I have learnt that the person sitting opposite can easily have different values to you. This course teaches a little of Aboriginal values. Had I been armed with some of this information, there is no doubt my earlier encounters with Aboriginal people would have been more successful.The joys of hindsight! While it is impossible to properly evaluate the whole course here, it is helpful to look at some ‘teasers’.

Facts and figures that struck me• InWAtheNative (Citizenship Rights)

Act, of 1944, forced Aboriginal peoples to choose either Aboriginality or citizenship

which they could achieve by proving to a magistrate they had severed all ties with their extended family and friends, were no longer associating with other Aboriginal people, were free of disease, would benefit from citizenship, and were of ‘industrious habits’. The practice continued until 1962 Commonwealth legislation.

• PinjarraisrememberedbecauseofanAboriginal massacre there.

• MoreAboriginaland/orTorresStraitIslander people (37%) than non-Indigenous people (22%) do not drink alcohol at all.

• Aboriginaland/orTorresStraitIslanderspecific funding represents 1.58% of total Government spending (roughly equal to foreign aid and about $1,500 spent per person).

• The1997National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from their Families report concluded, amongst other things, that: between 10-30% of A&TSI children were forcibly removed from their families and communities between 1910-70; the majority were removed in infancy with all that flows from this; they are no better off

medicalforum 23

Understanding Indigenous Health

Traditional Western public health approaches continue to fail Indigenous people in improving health outcomes and the majority of interventions are developed and implemented with little or no understanding of Indigenous people’s realities. Many Indigenous Australians regularly experience racism and discrimination which impacts on their access to and trust towards doctors, hospitals and social services. This results in poor health outcomes and causes dramatic disparities in chronic diseases and palliative care compared to the wider population.

Why cultural competence is importantCultural competence is often defined as a set of behaviours, attitudes, and policies that combine to enable an agency or individual to work effectively in cross-cultural situations.1 Cultural competence is a critical component of clinical competence and can improve Aboriginal health outcomes and build organisational capacity. Each Aboriginal community is unique in its culture(s) and history, and services need to be provided in ways that respect this. Unresolved

prof pat dudgeon and a/prof roz Walker from the Telethon Institute for Child Health Research discuss cultural competency.

trauma, grief, and loss are potentially volatile issues, which, if dealt with insensitively, may increase psychological distress in communities. So it is essential that all health practitioners have the cultural competence to effectively deliver services to Aboriginal people.

Current directions Fortunately, there are some very good initiatives happening across the health sector. The NHMRC Centre for Research Excellence at the Telethon Institute for Child Health Research is examining ways to enhance individual and organisational cultural competence throughout the professional arena and in association with bodies such as the Women’s and Newborn Health Network and the Australian Indigenous Psychologists Association. Cultural Competence Assessment Tools have been successfully trialled at KEMH and PMH and Cultural Competence workshops have been successfully held for mental health professionals.

addressing racism in aboriginal healthAboriginal people need to have access to Aboriginal initiated and controlled health services, and culturally appropriate mainstream services. All mainstream services need adhere

to sound principles underpinning organisational cultural competence. They need to be flexible and responsive to the community’s needs and should involve community members in the design, delivery, and evaluation of services. They need to provide social, emotional and mental healthcare in primary health care settings and be integrated with other health and specialist services to support referral and coordinated care.If we don’t commit to positive social change— if we don’t own the racism in our country and professions, we will never become a just, equal and well society in which we can all share and benefit from. Positive change will be achieved by increasing the number of Aboriginal people employed across the health sector and, through changing systems and the individual practitioners and professions within the systems. Reference1 Cross, T.L. et al 1989. Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed. Washington DC: CASSP Technical Assistance Center, Georgetown University Child Development Center. l

today so it was not in their ‘best interests’; many people now have nowhere to belong, and no sense of identity; at least 1 in 10 were sexually abused; grief amongst those left behind has greatly affected health and morale.

• TheGurindjistrikeofAboriginal stockmen for fair pay started the demand for a return of their lands, led to the 1976 Aboriginal Land Rights (NT) Act and was the inspiration for Paul Kelly’s song ‘from little things big things grow’

The Aboriginal world view• Theconceptof‘spirituality’referstoa

more holistic view of life – in particular an individual’s link with the land, sea and air. People are custodians of the countryside (not owners).

• Healthandwellbeingarelinkedholistically(not separated as environmental health, social wellbeing etc).

• Inanon-hierarchicalsociety,knowledgeof life, practical and intellectual, is what earns an individual respect and status (not achievements of status, power, academia).

• Resourcesaresharedamongsteveryoneinthe group (not just family, as ‘earnt’ and paid for).

• Aboriginalsocietyemphasisesmembershipof a group (not the achievements of the individual). An intricate, interconnected system of relationships, with each person having responsibility and obligation for someone else within this system.

• KinshipknowledgeformanyAboriginalgroups has been greatly affected by forced

removal to missions, placing disparate groups together, the removal of children from their families, and the forbidding of Aboriginal language and cultural practice.

There is much more to learn online about ‘The Intervention’ in the Northern Territory, The Apology, Self-Determination, the relationship between appalling health statistics and social inequality, Myths and Misconceptions, and so on…understanding is a start. l

indigenous healthtraining

guest Column

Photo courtesy WA Country Health Service

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26 medicalforum

Healthy Journalism in WA

medicine and the mediaMr Jake Millar

There is little doubt journalism is undergoing a serious change. The growth of the internet and 24-hour news channels mean stories can be broken around the clock, though does this mean we are getting quantity over quality? And are medical interests getting better at manipulating the media? Medical Forum spoke to two seasoned WA journalists.

uncertain times for print media

“Journalism in general is at a bit of a cross roads. The traditional institutions are cutting back on their number of journalists and they’ve typically chased larger audiences with less high-brow content,” said Mark.

“Against that you have the rise of electronic media, which allows new organisations to enter the fray and also a different group of people – the average person, the citizen journalist, as some people call it.”“Climate change is a really good example because where a debate may have been held 20 years ago in the pages of a couple of newspapers is now the domain of dozens of blog sites and specialist media.” Cathy has seen other changes in the last five years. “Online reporting has had a fairly big impact on paper reporting and how we operate. When I started out you wrote something that day and not much would change, whereas now news can change by the hour.”“People don’t necessarily religiously sit down and read a newspaper for an hour each morning, nor do they sit down and watch TV news for an hour at night. So people are often more interested in snippets.”

Shorter deadlines, government bureaucracy and PR are just some of the things hampering accurate reporting but does it really matter? The West’s Medical Editor Cathy o’leary and WA Business News Editor at Large mark pownall speak to Medical Forum.

Government bureaucracy, PR spin and shorter deadlinesIn her 22 years as a health reporter, Cathy said one of the biggest changes is the growth of the public relations industry.“Sometimes it’s hard to chip away at the PR spin and work out what is the legitimate story, and the 48-hour news cycle means things come in and out of news pretty quickly.”“The pharmaceutical industry has a fairly well-oiled public relations machine now, as do other groups as well.”In contrast, she said getting information out of government groups can be difficult, particularly when you are chasing a shorter online deadline and there is the bureaucratic vetting process to undergo. She tries to combat this by keeping a good network of close contacts.“Often the people I deal with in government have to wait on responses from higher up in the pecking order, which can be a difficulty. There can be some logistical issues, particularly if there are different government departments or if it’s across federal and state jurisdiction, trying to work out who’s responsible for what.”Getting accurate information in the first place can be a challenge but Cathy said she has developed a fairly good sense of who is pushing their own agenda.“Everyone probably has their own vested interest and you just take that on board. If people clearly have an agenda, it’s important to make that apparent to the reader. At the end of the day you try to give everyone a fair say and leave it up to readers to make their own assessment.”

Objectivity versus opinionAlthough objectivity might be an ideal, Mark said it is more a theory than a practice.“Over most of the time that I’ve been involved in journalism I’ve been very cut-and-dry about objectivity. But the truth is, what is objectivity? Everybody comes in with a view and as they get older and more experienced, their views change for a variety of reasons.”However, he said objective reporting is not the only thing newspapers offer, as many readers are now also looking to the media for opinion.“Consumers are getting smarter and they understand the media’s now a little bit more of that commentary and views game, so they tend to gravitate towards people who provide news and views,” Mark said.In fact, he believes the rise in opinion has helped to keep newspapers relevant.“People talk about newspapers and their demise and probably prematurely in my view. The organisations that can package the most views and commentary and add the most value to the news will probably be able to charge for it.”Cathy said health reporting is still of high interest to readers, mental health especially. Readily available news is pushing newspapers in a different direction.“Any medium can report news as it happens – people can read news as it happens on mobile phones – so I think the challenge for newspapers is to have more exclusive stories, with longer and more in-depth features,” she said.“I think that’s where newspapers and news magazines are headed.” l

28 medicalforum

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WA Cancer Funding – Small Fish?

Wa research FundingmF

WA is relatively small fry in the international research community and researchers here struggle to maintain that critical mass of people to attract the resources it needs. While on the one hand this spawns innovation, on the other it puts researchers clearly in the spotlight to justify their public purse spend. WA Health is ahead of the game with its recent release of Cancer Research and Funding in Western Australia, an Overview From 2008 to 2010 , a comprehensive review which we have examine here, along with comment from Prof Lin Fritschi on some related issues.

Cancer Council WA’s 13% Research FundingProf Lin Fritschi said that last year the Cancer Council found there are 28 organisations in WA asking for a piece of the cancer funding pie – most through private donations – but less than half support cancer research. Lin’s legitimate question as a researcher is where is the rest of the donated money going? Around half of cancer research in WA is funded by the NHMRC, followed by the WA Cancer Council (13%) and the State Government (6%).The Cancer Council relies on private donations alone to fund research projects, so in this regard, it competes for the donation dollar with the 27 other organisations in WA. (The State Government funding it receives is used for awareness campaigns, such as the Make Smoking History and Go For 2 and 5 healthy eating campaigns.)As well, there are around 13 national non-government organisations in Australia supporting cancer research. Lin said some of these were significant, such as the Prostate Foundation and the Breast Cancer

Cuts to research funding have taken up media time recently, bringing focus to bear on fragmentation within an ‘industry’ that relies largely on government funds for specific research ‘projects’.

Foundation, which contributed around $0.8m and $0.6m a year, respectively. However, many others contribute sums as low as $1000. Lin wonders if it is more sensible if smaller amounts were combined into big research grants.For mainstream government-funded research, each year a panel of 10 NHMRC experts from around Australia ranks all applications from best to worst. Lin said the state governments can improve the success of applications by funding infrastructure. “Particularly the biomedical, lab-based end of medical research – the machines they need that are outrageously expensive, which allow them to do particular experiments and gives them an advantage.”In any event, the NHMRC ends up funding the top 20% (it used to be 35%) and the Cancer Council uses the baseline science assessments of the NHMRC to look at unsuccessful applications, and perhaps tweak priorities towards research projects done more in WA with a particular WA relevance, before awarding grants. They also hand out a couple of research fellowships that pay the wages of researchers for a defined period.Lin said the rigorous funding process at the Cancer Council gives smaller non-government foundations better access to larger grants, and they are happy to combine efforts with other research grant bodies.“Last year we combined with the Lion’s Cancer Institute – they had enough money for one grant which was $70,000 and we supported it by putting it through our grant system.”“What worries me are charities that collect money and don’t do research, where is that money going? I went into a shop the other day and there was a very small children’s cancer charity collecting money. You do wonder how much use is it actually having, and if it is better to combine charities instead of creating new ones.”Not knowing is one thing but where we direct donations is another. Lin admitted that when the Cancer Council surveyed its donors a couple of years back, providing services for people with cancer was placed ahead of cancer research by survey respondents.

Prof Lin Fritschi is not only Cancer Council Research Grants Committee Chair, she also heads the Epidemiology Group at the WA Institute of Medical Research. Her forte is occupational causes of cancer, particularly exposure assessment in epidemiological studies. Her apparent conflict of interest (both handing out and receiving research grants) demonstrates how relatively small and tight-knit the research community is in WA. It also highlights the need many researchers have to collaborate across Australia and internationally in order to succeed, something that was not examined by the recent report on WA cancer funding even though the reports admits “at this point in time there is little coordination of the provision of cancer research funding either at a state or national level”.

medicalforum 29

First Medical Certificate: getting it rightOne of the most critical tools in the workers’ compensation system is also one of its understated - the First Medical Certificate.

The First Medical Certificate is used to start the process of payments to an injured worker. It provides vital information to employers and insurers on medical management of the claim. The certificate can also provide the employer with ideas of how they might modify workplace duties to accommodate the injured worker’s medical needs and help them return to work. Further still, these forms are the evidence used in disputes, helping everyone recall when memories or other information sources fail us.

With such emphasis on the Certificate throughout the workers’ compensation system, the care taken by the treating practitioner to complete properly can have a significant bearing on the outcomes of both the workers’ claim for wages and payments, as well as their successful return to work.

A successful First Medical Certificate:

• accurately and objectively diagnoses the injury and the limitations caused by the worker’s incapacity

• certify the worker’s fitness for work and gives clear guidance on any work restrictions that may need to be factored into their return to work planning

• correctly records the date of the consultation, as post-dated or ante-dated certificates can result in a worker’s claim being rejected or delayed

• outlines a plan for future appointments or other proposed medical management.

While the temptation may be to sign a worker off as “unfit for work” for weeks on end, research shows that prolonged time off can actually risk a successful return to work. It is in everyone’s best interests for the treating practitioner to explore options to get the worker back into the workplace as soon as possible, whether that be undertaking alternative duties or reduced hours. In this way the worker can still participate effectively in the workplace, socialise with their colleagues, and maintain financial stability as they recover from their injury.

WorkCover WA is keen to hear about how we can improve the certificate and other processes to make the workers’ compensation scheme more efficient.

I encourage you to email your comments and suggestions to corporatecommunications@workcover.wa.gov.au or phone on 1300 794 744.

By Michelle ReynoldsChief Executive Officer, WorkCover WA

Advisory Services call centre 8am – 5pm weekdays 1300 794 744

Workers’ Comp matters

Workers’ compensation and injury management scheme

The Cancer Research AuditCancer Research and Funding in Western Australia, 2008 to 2010 was produced by The Cancer and Palliative Care Research and Evaluation Unit (CaPCREU), a collaboration between Curtin University, Edith Cowan University and UWA. Ironically, this Unit was established with $4m funding from the WA Government during the time of the report, which temporarily inflated the State’s figures for cancer research at a time the report was expected to provide leverage for more state-based support. Report investigators were Prof Christobel Saunders (CaPCREU Director), Assist/Prof Claire Johnson, and Dr Toni Musiello, all from UWA School of Surgery.The audit was completed by acquiring information from, amongst others, organisations that fund or administer cancer-related research, and key researchers found via word-of-mouth, websites and clinical trial registers. Interestingly, less than one third (n=72) of the acquired masterlist of individual researchers responded to requests for information and one public hospital failed to respond at all. Cooperation with information on non-competitive research funding was limited. However, it found a total of 249 grants were awarded for 242 individual research projects, ranging from $1,058 to $4m – and 219 of the grants were regarded as competitive.

some Key Findings•2008-2010directfundingtoWAcancer

research projects and programs was $34.6m – NHMRC 50% and Cancer Council 13%, with 92% going on specific research projects, followed by scholarships, fellowships and chairs (7%).

•Researchallocationbyresearchtype(orCommonScientificOutline) was: Biology 40%; Treatment 23%; Cancer control, survivorship & outcomes 12%; Early detection, diagnosis & prognosis 8%; Etiology 6%; Prevention 6%; and Scientific model systems 5%.

•Biologyresearchorprojectsofabasicsciencenature(i.e.notspecific to a particular cancer) received most funding – lung, haematological, genitourinary, breast and head and neck cancers were top of the list.

• Lung,brainandleukaemiacancersallreceivedlargeramountsoffunding than their incidence rates. Breast cancer showed relatively matched incidence and funding. In general, the pattern of funding by disease site did generally follow the level of burden of cancer by disease site.

• Whencomparedtoperson-years-living-lost(PYLL),diseasesitesthat appear to be overrepresented in cancer research funding include prostate cancer (in competitive grants and clinical trials), leukaemia (in competitive grants) and breast cancer (in clinical trials). Areas that appear to be underrepresented in competitive grants are melanoma, liver, oesophagus, ovary, pancreas, stomach, kidney, and colorectal cancers.

• TheWAstategovernmentprovidesmainlynon-competitivefunding (79% of non competitive research projects) that is limited and nonrecurrent (mostly general research and in the area of cancer control, survivorship and outcomes).

• Ofthe110clinicaltrialscurrentlyopeninWA,65%wereinbreast cancer, haematological, lung and genitourinary cancers (but audit information was limited). Mostly, the coordinating institutions responsible for administering clinical trial grants are located outside WA.

• Reportshortcomings:smallerfundingorganisationsarelikelytobe under-represented in the report; researcher collaboration was not covered by the report – the National Audit in 2005 found that the vast majority of collaborations within the same institutions, city and states; it is possible that the number of grants and amount of funding awarded for infrastructure, equipment, and scholarships, fellowships and chairs is higher than presented. l

30 medicalforum

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= 30-90% dose reduction compared to standard CT

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medicalforum 31

C L I N I C A L U

PD

AT

E

By Ms Jo Beer, Dietitian and diabetes educator.

Tel 0403 938 747

Using Glycaemic Index with weight loss and diabetesThe glycaemic Index (GI) was promoted as a weight loss method in the 90’s by nutritionist Jennie Brand-Miller

in books such as The New Glucose Revolution and GI Plus. It has also been introduced into popular culture through the weight loss game show The Biggest Loser. A number of advisory groups (including Diabetes Australia) now promote low GI diets for managing type 2 diabetes and reducing the occurance of ‘hypos’ in those with type 1 diabetes. . However, some authorities recently suggested that there is an overemphasis on the role of GI in diabetes and weight loss. They have also raised concerns that use of the low GI symbol can be confusing.

What is gi?The GI ranks carbohydrates according to their effect on blood glucose levels (BGL). The scale ranges from 1 – 100, with glucose scoring 100. Low GI food is rated 55 or less, medium 56 – 69 and high GI 70+. In general, the more processed a food, the higher its GI.High GI foods produce rapid rises and falls in BGL, provoking an insulin spike that long term can increase the risk of diabetes and weight gain. Slower sugar release from more complex carbohydrates (lower GI foods) moderates blood glucose and insulin levels, assisting in diabetes management and weight loss.

pitfalls of a low gi dietPopularisation of the GI has led to some patients unnecessarily avoiding all high GI foods. For example, I have had several patients with diabetes who avoided potatoes for many years because of GI concerns. Jacket potatoes have a GI of 69, but at about 100 calories per 150 gm and less than 0.1% fat, they can still be a healthy choice and certainly favourable to low GI foods such as chocolate and ice cream! The GI also only measures the individual food and not the whole meal, nor the total amount of carbohydrate (the glycaemic load). Furthermore, protein and vinegar can reduce gastric emptying, effectively lowering a meal’s

GI - adding a dressed salad or chicken to the potato can reduce the meal’s GI. It is a fashionable misconception that foods should be eaten or avoided depending solely on their GI. A low GI certainly should not be considered as a licence to eat unlimited amounts, or even that the food is necessarily healthy.A recent scheme to identify low GI foods with a symbol has been launched by diabetes interest groups. Foods also have to meet criteria for salt and saturated fat content, but this can create the erroneous impression that foods lacking the symbol must have a high GI.

What to advise• ChooselowGIfoodsmostofthetime–

aim for one per meal – so choose oats for breakfast, add beans to a jacket potato or lentils to a vegetable soup. For more ideas visit the glycemic index website below or look out for one of the official glycemic index books at the library or in the book shop.

• Controlportions–seegovernmentrecommendations below

• Chooseunprocessedfoodswithabundantwholegrains, lean protein, fresh fruit and vegetables

• Exercisedaily

useful patient resources:www.diabetesaustralia.com.au/www.glycemicindex.com/www.gisymbol.comwww.health.gov.au/internet/healthyactive/publishing.nsf/content/recommended-daily-servings n

coronary ctMake the right choice

• Integrated Cardiology and Radiology

• Every scan read by an accredited specialist

• Dual source CT – faster, sharper and purpose built for Coronary CT

• Preferred provider for many of WA’s leading cardiologists

Lower dose radiation – every patient every time

CT • MRI • X-RAY • ULTRASOUND • NUCMED • DENTAL

Australia’s only NoCO2 accreditedMedical Imaging Practice

t: 08 6382 3888 f: 08 6382 3800 e: info@envisionmi.com.auw: www.envisionmi.com.au

178 Cambridge Street (opp. St John of God, Subiaco)Free parking at rear of building

t: 08 6382 3888 f: 08 6382 3800

e: info@envisionmi.com.au w: www.envisionmi.com.au

Australia’s only NoCO2 accredited Medical Imaging Practice

Lower dose CT scans for all

Cutting-edge CT technology delivering:

1. Iterative reconstruction (30-50% dose reduction for all) 2. Tailoring of X-ray voltage (further 50-75% reduction for medium/small patients)

3. Dual energy = virtual non contrast (30-50% dose reduction for select cases)

= 30-90% dose reduction compared to standard CT

CT MRI X-RAY ULTRASOUND NUC MED DENTAL

Conference Corner

Visit www.medicalhub.com.au for more information and click on ‘events’.

australian diabetes society & diabetes educators asm

Dates: 31/8/2011 31/8/2011

Venue: Perth Convention Centre

Website: http://www.ads-adea.org.au/

For more information phone (03) 5983 2400 or visit the website.

asia pacific autism ConferenceDates: 8/9/2011 10/9/2011

Venue: Burswood Entertainment Centre

Website: http://www.apac11.org/

For more information phone 9389 1488 or email info@eecw.com.au.

32 medicalforum

NOW AT 3 LOCATIONSLEEDERVILLE, JOONDALUP & BUNBURY

For ALL appts/queries: T:9422 5400 f: 9382 4576E: info@pivet.com.au W: www.pivet.com.au

FERTILITY NEWS Medical Director Dr John Yovich

PIVET MEDICAL CENTRESpecialists in Reproductive Medicine & Gynaecological Services

The attached picture shows a human metaphase-II egg with polar body and sperm attached to the surrounding zona pellucida. This photo was taken in my Laboratory at the Royal Free Hospital in London in 1977, a unique feature at its time being a year prior to the first IVF success – Louise Brown in July 1978.

Currently there are around 4 million babies from IVF and a large proportion are generated following embryo freezing with the first successes reported in 1984, PIVET following soon after in 1985.

However the technique of egg freezing proved more difficult until my close colleagues in Tokyo – Osamu Kato & Masa Kuwayama whom I helped establish their IVF Clinic 20 years ago, working with our Professor Gabor Vajta, re-invented a Vitrification technique known as Cryotop. The Holy Grail was discovered with excellent results and PIVET has been reporting many pregnancies now from banked oocytes over the past two years. Eggs can be banked by young women deferring pregnancies for their own subsequent use or for other women requiring egg donation.

In March this year our sister clinic Cairns Fertility Centre reported its first baby – a healthy girl – following a donor egg pregnancy derived from our Vitrification Egg Bank and others are now underway. In WA all assisted reproductive procedures are highly regulated under restrictive State legislation whereas Queensland functions

under National regulation which enables far more freedom within the various donor programs.

Egg Banking Viable

The Australian Research Alliance for Children and Youth (ARACY) delivered a damning Report Card in 2008 for child mental health and wellbeing. In the ‘lucky country’, our children and youth’s mental health outcomes are poor, being rated 18 out of 24 compared to other OECD countries. Shamefully, our indigenous children are ranked 23rd. What does this say about the priorities of our resource rich nation?

Raising mentally and physically healthy children provides obvious benefits that flow on to all of us. It promotes increased productivity, greater social inclusion, and reduces public expenditure. The National Early Childhood Development Strategy, Investing in the Early Years, asserts that the shared vision of the commonwealth, state and territory governments is that by 2020 all children will have the best start in life to create a better future for themselves and for the nation. This rhetoric is yet to be transferred into effective policy.Those who raise children have the most powerful influence on their development, yet we skimp on evidence-based supports and interventions to families at this vital period and invest in services too little too late. Young children who experience recurrent abuse and neglect, witness violence, or live in homes with family dysfunction, substance abuse, and maternal depression are particularly vulnerable and at substantially increased risk of developing serious emotional and behavioural problems, learning difficulties and just as importantly, future major physical health problems.It is remarkable how little attention service planners devote to strengthening the capacity of child and adolescent mental health services, in view of the overwhelming data that supports the need for this. Increasingly, the needs of infants, young children and their families are being overshadowed by a focus on the mental health needs of youth, despite infancy and childhood being a more critical time in development.Only 10% of our mental health budget is allocated to child and adolescent mental health services, although children and adolescents make up more than 25% of the population. This provides resources for the most severe and complex mental health problems, ensuring GPs and other referrers struggle to get access for children who have less severe and entrenched disorders but no access to comprehensive services. This, despite all evidence that preventive early identification and treatment of emerging mental health problems is far more cost-effective.Effective and responsive early childhood services optimise universal, targeted and intensive services that need to be well-coordinated, interdisciplinary and flexible. The recent integration of Child and Adolescent Mental Health services into a single service within Child and Adolescent Health Service is an important opportunity to achieve this, but substantial further investment is required.To date the responsibility to provide responsive mental health services to infants, young children and their families has been ignored. We will again fail the next generation if we neglect their needs during this vital stage of development, at great future cost to our health system and society. l

Faculty of Child Psychiatry Chair dr Caroline goossens explains why greater investment in child and youth mental health is a good idea.

guest Column

Early Intervention in Mental Health of Young

34 medicalforum

Diabetes affects the eyes and diabetic retinopathy is the leading cause of blindness in our community. However, diabetes can affect the eyes in many different ways, as briefly outlined here.

ocular surfaceOcular infections such as conjunctivitis and blepharitis are more common in diabetics. Symptoms are often exacerbated by dry eye, which occurs more frequently due to poor tear-production, reduced numbers of conjunctival goblet cells and reduced corneal sensitivity (probably related to diabetic neuropathy). Frequent lubricating eyedrops and eyelid cleaning may reduce symptoms. Antibiotics are usually not indicated. Patients should be counselled about meticulous contact lens handling to prevent infections.

lensBlood glucose fluctuations can influence the refractive index of the lens, resulting in refractive errors that usually normalise after control of the blood sugars.Cataracts are more common in diabetic patients and those with more severe retinopathy or maculopathy tend to have a worse outcome from surgery as there is an increased risk of worsening retinal disease if this is not adequately controlled pre-operatively.

retinaDiabetic retinopathy and maculopathy are most common. Macular disease tends to cause central vision loss. Pathophysiologically, there are many changes within the retinal vessels that result in ischaemia or oedema of the retina.Clinical signs of retinopathy include haemorrhages, cotton wool spots, beading of veins and other microvascular anomalies. The formation of abnormal blood vessels on

the optic disc (NVD) or peripheral retina (NVE) heralds the onset of ‘proliferative’ diabetic retinopathy. This is a severe complication and requires urgent laser treatment to prevent vision loss.Maculopathy is the commonest cause of vision loss in diabetics – the central retina becomes oedematous or ischaemic. Signs of maculopathy include hard exudates and retinal thickening. Until recently, the only effective treatment for macular oedema was retinal laser. Now, intravitreal injections improve vision. Risk factors for retinal disease include poor long-term control of sugar levels and disease duration, as well as smoking, systemic hypertension and obesity. Type 1 diabetics usually have more severe disease.Lipaemia retinalis is a rare ‘curiosity’ sometimes found in diabetics, where abnormal lipid control results in transient severe hypertriglyceridaemia following a fatty meal. Retinal vessels appear creamy pink. It is visually insignificant (fig 2).

Optic nerve and other cranial nervesPrimary open angle glaucoma is more common in diabetics. Diabetic papillopathy is a benign swelling of the optic nerve head. There are no signs of optic neuropathy and no intracranial pathology. It resolves over time with improved blood sugar control.Other cranial neuropathies are common. Typically, diabetic 3rd nerve palsies are pupil sparing. Most spontaneously resolve after three months.

This clinical update is supported by the Eye Surgery Foundation n

n Fig 2. Lipaemia retinalis - before a fatty meal (top) and 30 mins after (bottom).

n Fig 1. Diabetic retinopathy and maculopathy.

Diabetes: ophthalmic manifestations

CL

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40 medicalforum

Creating the perfect getawayDr Sharon Masel and her husband Dion bought their Pemberton property with future kids in mind. “We both loved the big old trees of Pemberton and thought buying a big farm with river frontage could at least teach our future children there is more to life than DVDs and com-puter games,” Sharon said.

But it was not long before Dion’s experience building a safari lodge in his native South Africa and Sharon’s entrepreneurial spirit took over, and the idea of creating the perfect country B&B was born. A conversation with friend and award-win-ning architect Aviva Shpilman sealed it. It would be in the style of an old European stone barn.

They orchestrated an army of stonemasons and tradesmen to hand built it from scratch. Dion organised construction and Sharon designed the interior.

“I was in Perth working as a gastroenterologist with two very young children while my husband worked five half-days a week on site for close to two and a half years... aarrgghh!”

“Luckily, since we opened, we have had great managers on site who have returned my hus-band to me!”

To their credit, Stonebarn has won many acco-lades since. The getaway was a finalist in the Australian Interior Design Awards after opening its doors in 2009. It has been twice shortlisted for the WA Tourism Awards, and they have been featured in magazines and newspapers around the world.

But they are not about to rest on their laurels. Six years ago they planted their first truffles, and they are now expecting their second harvest in June.

“My friends laugh at the similarities between the

Whether running a boutique resort, starting a vineyard, producing olive oil or making chocolate, you have to find both the passion and the time outside medicine! the stories of these four doctors will fascinate.

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truffles and what I might see by day as a gastro-enterologist. My brother, a dermatologist, tells me he spends all day trying to eradicate fungus while I try to grow it!”

Chocolate indulgence

tony said it was “just general boredom” that started him on the chocolate road about five years ago.

“I enrolled in a class thinking it was going to be only bored housewives, but when I turned up we had the number-three chocolatier in the world teaching us and I was thrown in at the deep end.”.

Tony was hooked and found making chocolate surprisingly simple.

“I find it totally relaxing. But chocolate melts at body temperature so once the weather’s above 30°, you’re in big trouble unless you’re in air-conditioning. You probably need specialised moulds but other than that, there’s not much. You can melt chocolate in a high-class melter or a microwave if you like!”

“The biggest difficulty is getting access to good quality chocolate, not compound choco-late like Cadbury’s. There are all sorts, whether you’re using combinations or just chocolate from one particular plantation.”

He always looks to push the envelope but he said flavouring chocolates is about subtlety.

“Someone was doing a chilli relish so I devel-oped a chilli chocolate for them using their relish inside. About 4000 chocolates sold with-in half an hour. You should enjoy the chocolate and then most of the flavours come through on the aftertaste – it’s got to be a chocolate first. At the most I’ll have one or two chocolates a day because I’m still getting waves of flavour two or three hours later. They’re just awesome things.”

His skills have been noticed.

“I’ve taken out first prize at the Perth Royal Show for the last two years, and last year I actually sculpted my hand as part of a pres-entation. There’s always something else to try. The beauty about chocolate is it’s not just culinary, it’s chemistry and physics as well. You spend a lot of time learning the physical properties of sugars and gels, and which tem-perature to use.”

“It’s spectacular and really good fun,” he said.

Dr Sharon Masel and Stonebarn luxury B&B

Dr Tony Barr and his floral chocolate creation.

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A love-hate affair with olive oilDonnybrook GP Dr Peter Rae planted his first olive trees in 1996 and it has been a love-hate relationship ever since.

“Our home at the time had a small orchard alongside it with about 40 fruit trees and a cou-ple of olive trees. It always used to bug me that the fruit fly got into the stone fruit and the parrots ate all the apples – meanwhile nothing seemed to affect these two olive trees and they flourished, full of fruit.”

“I thought why waste so much time with fruit? Why not put some olive trees in? I probably should have admitted myself to Graylands to get over it but I didn’t, and we ended up buying some 35 acres and put an olive grove in.”

Peter now tends a handful of varieties and there is more to olives than meets the eye.

“Olive trees are funny things, the same cultivar can have different names in different places and a lot of them are hard to tell apart without genetic testing. They have genetic mosaicism, where the genetics can vary from one part of the tree to another, so it’s a bit of a tricky busi-ness at times.”

A full time rural GP, Peter finds time on week-ends to tend his grove and once a year, spends two weekends harvesting and preparing most of the crop for pressing, before selling under his Elkanah Grove label. One is a Tuscan blend of five different olives, and the other is made solely from leccino olives. The latter won a gold medal at the Perth Royal Show last year.

Peter’s advice for those looking to enter the olive oil business? “Don’t do it! I dream of bull-dozers after every harvest!” he jokes.

“We’ve got about 850 trees and it’s probably too much for me to look after, especially as they get bigger and it becomes quite a difficult pro-

cess pruning them and so on.”

No-one gets rich on olives, Peter suggests, pointing to the failure of the big investor groves.

“But I really like the trees, because they’re just wonderful and the olive oil is great.”

top end winemakingDr Michael Peterkin, the number one bloke behind Pierro wines, said his interest in wine started in medical school. “A professor of pae-diatrics, Bill McDonald, took us to Houghtons in the Swan Valley when we were in fifth year, so we got an introduction to wine as part of our medical training.”

“I graduated in 1973 from UWA, worked for a couple of years and then I went to an agricul-tural college in South Australia in 1976-78 to study winemaking and grape growing.”

He was then half in medicine, half in winemak-ing before he linked up with Dr Kevin Cullen at his Busselton practice. Michael set up his first vineyard in 1979 and for the next 25 years practised fulltime – including obstetrics, anaes-thetics and A&E – and ran the vineyard in his spare time.

“The thought of being involved in the develop-ment of a major wine growing district from the ground floor was very exciting. It was pretty intense because I’d drive home from work and then I’d be at the vineyard for an hour or two in the evenings. All my holidays were taken up picking grapes and making wine.”

He said things are much more relaxed these days, especially since he semi-retired in 2003 and is now virtually fulltime as Pierro’s senior wine maker and viticulturalist.

“We’re renowned for making Chardonnay at Pierro and the reds are now also developing very well. But the reputation has been built on Semillon Sauvignon Blanc and Chardonnay.” He said they made the first SSB in Australia! And the Pierro Chardonnay is considered one of Australia’s top five.

Michael’s tip for those looking to follow in his footsteps?

“Start young. It’s not as facetious as it sounds because they’re businesses that take a long time to really get up and running. Our aim has been to produce the best wines possible and you need mature grapevines to do that.”

It has taken him 20 years to establish a suc-cessful wine business, and he says there is no substitute for a solid grounding in winemaking.

“Otherwise you’re in the hands of the con-sultants and you don’t know whether they’re correct or not. There’s no substitute for know-ing what you’re doing. I planted the grapevines and physically made all the wines myself for the first 15 years or so, so I know the business from the ground up. I’ve also had a lot of fun along the way as well.”

Peter’s award-winning Elkanah Grove olive oil.

Dr Peter Rae and wife Christine.

Dr Michael Peterkin

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Dr Charles Armstrong is an obstetrician who works mostly at Mercy Hospital, and he recently dropped by the Medical Forum office to pick up his fine selection of wines from Old Kent River.

He kindly told us he enjoys reading the maga-zine and takes particular interest in the wine review and lifestyle section.

When he’s away from work and has a spare minute or two, Charles said he enjoys photog-raphy but he also has four children who take up most of his time.

Although he’s often busy, he does try to find time to open a nice bottle of wine and enjoy the occasional glass. Now he has got a dozen of Old Ken River’s finest on his hands, he’ll have to make a special effort.

Competition Winners for april

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By Dr John Quintner

drugging during pregnancyBut if the woman escapes with dear life the ailments incident to puberty, other perils are before her. In the common order of events, the matrimonial relation is formed. Then come child-birth and nursing, with all their joys and sorrows. Lucky is the woman who can, on these occasions, escape the doctor’s lancet and drugs. During pregnancy she usually suffers more or less of nausea, cramps, constipation, vertigo, etc., for which she is bled, physicked and narcotised, predis-posing her to hemorrhage, milk-leg, broken breast, and other sequelae, and multiplying the occasions for taking more medicines. From: The Health and Diseases of Women by RT Trall MD, 1872.

Advice well receivedA loving husband once waited on a physician to request him to prescribe for his wife’s eyes, which were very sore. “Let her wash them,” said the doctor, “every morning with a small glass of brandy.” A few weeks afterwards the doctor chanced to meet the husband. “Well, my friend, has your wife followed my advice?” “She has done everything in her power to do it, doctor,” said the spouse, “but she never

could get the glass higher than her mouth.” From: The Doctor, Dec 31, 1834

Good Food Guide 2011 – Dr Michael Benson, Dr Pek Goh, Dr Ken Collins, Dr Vijay Panicker & Dr Caroline Rhodes½ Price Art Classes – Dr Rebecca Doedens: Murdoch, Dr David Borshoff: Joondalup & Dr Mina John: Claremont

Something Borrowed: Movie – Dr Yin Yin Wee, Dr Sharyn Bennier, Dr Maria O’Shea, Dr Sara Gibberd, Dr Hui Jern Loh, Dr Sue Sparrow, Dr Mik Parola, Dr Ted Khinsoe, Dr Mike Bray & Dr Paul Kwei

Babies: Movie – Dr Daniel Heredia, Dr Christina Wang, Dr Martin Ibach, Dr Fiona Whelan, Dr Helen Mead, Dr Annette Finn, Dr Angelo Carbone, Dr Wei Ying Chua, Dr John Williams & Dr Vincenza Frisina

Get Low: Movie – Dr Richard Riley, Dr Brad Jongeling, Dr Andrew Kam, Dr Andrew Lim, Dr Ben McGettigan, Dr Luca Crostella, Dr Peter Melville-Smith, Dr Winston Choy, Dr Lydia Peter & Dr Robert Weedon